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Pharmacy Prior Authorization

Pharmacy Fee For Service Prior Authorization (PA)  Contacts

Change Healthcare Pharmacy PA Unit
Toll-free: 877-537-0722
Fax: 877-537-0720

Registered Users in the Change Healthcare PA Portal
If you are a Mississippi Medicaid prescriber, submit your Fee For Service prior authorization requests through the Change Healthcare provider portal.

Drug Prior Authorization Instructions (click here for instructions)

Please utilize the drop-down menus below to select the appropriate PA packet.

Prior Authorization Packets

Prior Authorization Packets Updated
Brand Name Multi-Source 6/21/2019
Early Refill 6/21/2019
Enteral Nutrition 6/21/2019
EPSDT – Beneficiaries Under 21 6/28/2019
Growth Hormone 10/1/2021
Hepatitis C Therapy 6/1/2021
Max Unit Override 6/21/2019
Multiple Concurrent Antipsychotics for Beneficiaries (Age < 18) 6/21/2019
Opioid Packet – Effective 8/1/2019       FAQs 9/10/2019
PDL Exception Request 6/21/2019
RSV-SYNAGIS®

DOM will begin accepting Synagis prior authorization requests on October 11, 2021 for DOS beginning November 1, 2021

9/30/2021
Universal Prior Authorization Form 6/21/2019

Manual PA Criteria

Please utilize the appropriate PA form listed under Prior Authorization Packets in drop-down menu above. 

Manual Prior Authorization Criteria Updated
Akynzeo 2/3/2020
Antipsychotics 2/3/2020
Austedo 6/10/2020
CGRPs 5/26/2021
Corlanor 2/3/2020
Cresemba 2/3/2020
Dupixent – Asthma 2/3/2020
Dupixent – Atopic Dermatitis 2/3/2020
Dupixent – Nasal Polyposis 12/27/2021
Emflaza 2/3/2020
Endari 2/3/2020
Eucrisa 4/1/2020
Evrysdi 4/6/2021
Exondys 2/3/2020
Farydak 2/3/2020
Hemlibra 2/3/2020
Ingrezza 2/3/2020
Jadenu 2/3/2020
Juxtapid 2/3/2020
Kalydeco 1/27/2021
Lotronex 2/3/2020
Lynparza 6/3/2020
Mavenclad 2/3/2020
Mayzent 2/3/2020
Ocrevus 2/3/2020
Orkambi 2/3/2020
Oxbryta 2/28/2020
Palforzia 12/16/2020
Praluent 10/27/2019
Probuphine 2/3/2020
Repatha 10/16/2019
Sivexto 2/3/2020
Stribild 2/3/2020
Sublocade 2/3/2020
Symdeko 1/27/2021
Trikafta 7/9/2021
Tybost 2/3/2020
Varubi 2/3/2020
Viltepso 1/21/2021
Vivitrol 2/3/2020
Vyepti 2/10/2021
Vyondys 53 1/22/2021
Zontivity 2/3/2020
Zyvox 2/3/2020

Physician Administered Drug (PAD) Prior Authorization Instructions

Alliant Health Solutions is the current vendor for physician administered drugs. Please click here to direct you to the Alliant official website.  As a reminder, please submit physician administered drug PA requests through Alliant.

Miscellaneous Forms

Pharmacy Reconsideration Request Form

MedWatch Form